Bariatric Times

Insights into Patient Pop with Obesity 2016

A peer-reviewed, evidence-based journal that promotes clinical development and metabolic insights in total bariatric patient care for the healthcare professional

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Bariatric Times • December 2016 • Supplement C C11 IlI + BArIATrIC SurGery The most invasive form of intervention is bariatric surgery—gastric band, gastric sleeve, or gastric bypass. 2 8 This intervention should always rely on ILI as the foundation and it should be used in patients who have tried or may still be utilizing AOM pharmacotherapy. The main criteria for bariatric surgery is that the patient have a BMI >40kg/m 2 or a BMI >35kg/m 2 with comorbidities. The gastric band is surgically placed to go around the stomach, which restricts the stomach space and thus limits food intake. The gastric band may be considered the least invasive of the bariatric surgeries. The gastric sleeve removes part of the stomach but it does not re-route any of the bowel system. The most invasive procedure is gastric bypass which both removes a portion of the stomach and re-routes the bowel system. The role of AOM with bariatric surgery is evolving. Some patients need even more signal interruptions to be successful with weight loss than are available with bariatric surgery alone. Some of the new medications may work well to provide bariatric surgery patients with this added support. Bariatric surgery is not utilized as much as is indicated. Early intervention can be particularly helpful for patients with type 2 diabetes mellitus as it may have a beneficial effect on the course of the disease. In fact, it may be helpful to think of bariatric procedures as metabolic surgeries rather than obesity surgeries. PCPs should be aware of the important role of bariatric surgery and when it is indicated—which may be at lower BMI values than many expect. Many patients under the care of a PCP might be appropriate candidates for bariatric surgery, but are not being informed about this option. It is not necessary for the PCP to understand the nuances of the individual procedures or to provide highly specific recommendations to the patient. A bariatric surgeon can be consulted and help advise the patient. FuTure DIreCTIONS IN weIGHT lOSS AND weIGHT CONTrOl The heritability of an individual's BMI has been estimated to be about 40 to 70 percent, 2 9 which roughly translates to the fact that about half of the differences in body weight can be traced to genetics and the other half to environment. The issue of genetics poses questions but may also offer future answers to better obesity management. Genetic variations have been associated with the relative success of ILI efforts, bariatric surgery effectiveness, and the variations in the macronutrient composition of diet. Genetics may also help clinicians prescribe the most effective weight loss strategies and therapies for an individual patient. It is now thought that areas of genomic influence/customized care, such as control of energy expenditure, appetite control and food intake, and adipogenesis and lipid metabolism, may be key components to weight loss. 30 How the body takes in energy and stores it varies by individuals and this information may be useful in finding the best weight loss strategies for the patient. In addition to genetics or genomics, epigenetics should be considered in that these describe the interactions between the patient's environmental factors and his or her genes. Epigenetics can allow clinicians to find the best individualized and customized care regimen. For example, physical activity and high-fat diets may alter DNA methylation, which, in turn, may affect the energy homeostasis in skeletal muscles and adipose tissue. Muscle tissue sends very specific signals to adipose tissue. Thus, specific physical activity plans can change the messaging of muscle to adipose tissue and, in that way, encourage weight loss. 31 Epigenetics has opened up new ways of clinically understanding weight loss, weight gain, and weight maintenance, the latter being a particularly challenging aspect of weight control. 32 By understanding the genes that regulate energy, it may be possible to find a more sustainable approach to weight loss and weigh maintenance. There are currently consumer tests available that Insights into the Patient Population with Obesity: Assessment and Treatment

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